Persistent Diplopia More Common Following Lower Blepharoplasty Than Thought

Close up of the face of a patient who is undergoing blepharoplasty. The surgeon cuts the eyelid and performs manipulations using medical instruments.
Despite a dearth of evidence in the literature, a survey shows many patients experience double vision after this procedure.

Persistent diplopia following lower blepharoplasty surgery may be more common than suggested in the current literature, according to survey results published in the Journal of the American Association for Pediatric Ophthalmology and Strabismus. 

Because diplopia following lower blepharoplasty is rare, the exact incidence of postoperative diplopia has not been determined. To rectify this, a researcher conducted a survey study of members of the American Society of Ophthalmic Plastic and Reconstructive Surgery (ASOPRS) to assess diplopia incidence. 

An internet-based survey was sent to 703 ASOPRS members. The survey included 13 questions about persistent diplopia (>1 week after lower blepharoplasty). Questions were focused on both provider experience — number of annual blepharoplasties performed, years of surgical experience, and number of cases with postoperative diplopia — and on patient and surgical details. Physicians who experienced more than 1 case of severe diplopia were instructed to focus on the most severe case. 

Among those who received it, 371 completed the survey, for a 52.8% response rate. 

In terms of provider experience, 24.3% of respondents performed fewer than 20 lower blepharoplasties on an annual basis; 35% performed 21 to 40, and 50.7% performed more than 40. In total, 23.2% reported experiencing at least 1 case of persistent postoperative diplopia, compared with 76.8% who experienced no cases. There was a statistically significant difference between groups in terms of persistent diplopia cases: 11%, 21% and 33% of physicians who performed 20 or fewer, 21 to 40, or more than 40 annual lower blepharoplasties experienced at least 1 case of persistent diplopia, respectively (P =.0005). 

Patient experience data were available for 84 cases. Persistent diplopia was most common among patients 41 to 60 years of age (61.9%), followed by patients 60 years or older. The inferior oblique muscle was most commonly involved in cases (60.7%), while involvement of the inferior rectus muscle was found in only 8.3% of cases. Slightly greater than 26% of cases involved a muscle that was not identified. 

Sixty-one patients (72.6%) experienced complete resolution of diplopia compared with 21.4% who experienced partial resolution and 6% who experienced no resolution. Most patients (37%) took >3 months to experience maximum improvement. Diplopia persisted in the primary position in 8.3% of patients and in other gaze positions in 19.1% of patients; however, 72.6% of patients experienced complete resolution. In terms of treatment, 8.3% underwent strabismus surgery, 4.8% underwent prism correction, and 86.9% required no treatment. 

Study limitations include a potential voluntary response bias, due to the voluntary nature of the survey, as well as the possibility of increased reporting of postoperative diplopia due to the anonymous nature of the survey. 

“Surgeons should be aware that persistent diplopia following lower blepharoplasty may be more common than is suggested by the relatively small number of reports in the literature,” the research says. “It is especially important for them to be mindful of this complication when performing a deep dissection in the medial or central fat pads.” 


Becker BB. Diplopia following lower blepharoplasty. J AAPOS. Published online November 25, 2020. doi: 10.1016/j.jaapos.2020.07.017